Background. Behavioural problems among schoolchildren can pose a
burden on families and society. Objective. To determine the prevalence
and pattern of behavioural problems among children living in Uyo, a town
in South-South Nigeria.

Methods. A cross-sectional study was carried out among 572 pupils
from six primary schools selected randomly from private and government
schools in Uyo. Pupils with a normal IQ were selected using a systematic
sampling method. The Rutter behavioural scale for teachers (B2) was
completed by their teachers, and that for parents (A2) was completed by
the parents. Student's t-test was used to compare pairs of means,
frequencies were compared using the chi-square test, and p<0.05 was
taken as significant.

Results. According to the teachers' scale 132 pupils (23.1%)
had scores within the range indicating behavioural problems, compared
with 103 pupils (18.0%) on the parents' scale. This was
statistically significant ([chi square] = 19.8, p=0.001). Pupils in
government and private schools had mean scores of 7.4 (standard
deviation (SD) 6.41) and 5.12 (SD 6.26) and 7.29 (SD 5.84) and 6.96 (SD
5.76), respectively. Behavioural problems were more common among
children in government schools and among those in the lower
socio-economic class. Boys had significantly higher mean scores than
girls, and both scales showed more boys to be disturbed. Antisocial
behaviour was commonest among boys and older children.

Conclusion. There is a high prevalence of behavioural problems
among primary school children in Uyo, with a predominance of antisocial
behaviour. The government needs to provide appropriate services to deal
with the state of affairs.

Behavioural problems in children can be part of normal development.
Such problems are often transient and may not even be noticed, and may
be exhibited in certain settings and not in others (e.g. at home and not
at school). In developed countries parents tend to seek advice even for
minor problems, such as persistent thumb sucking, while in developing
countries major psychiatric disorders such as childhood schizophrenia
may go unattended. Some schoolchildren exhibit a range of deviant
behaviour that may be a burden not only for parents and families, but
also for teachers, other pupils and even the community. (1-7) It has
been reported that about 10-26% of children in both developed and
developing countries have behavioural problems, and a single child can
have a range of problems. (3,6-8) However, the prevalence varies widely
depending on geographical location, culture, family characteristics and
socio-economic setting. (3,5) Standardised scales have been developed
for the assessment of behavioural problems in children in developed
countries. (9-11) The Rutter teachers' and parents' scales for
assessment of behavioural problems have been standardised for use on
Nigerian children. (3,12) These scales have been used in previous
studies to assess the prevalence of behavioural disorders in children in
western and south-eastern Nigeria. (3,6,8, 13,14)

In the study by Adelekan et al. in Kwara State, Nigeria, 846
parents completed the 31-item Rutter A2 scale for their children aged
6-14 years. (14) Using the Rutter cut-off point of 13, 18.6% were found
to have a behavioural problem. The prevalence of behavioural problems
was also evaluated among 620 United Arab Emirates nationals aged 6-18
years; (2) 11.8% scored above the cut-off point, indicating behavioural
problems. Conduct problems were more prevalent among boys and emotional
problems among girls.

Some researchers have examined whether behavioural symptoms or
deviant behaviour among children predict later psychiatric referral.
(15-17) Kumpulainen and Rasanen (16) assessed a total of 1 268 children
in Finland at age 8 and again 4 years later, at which time they found
that 3.3% of the study group had been referred for psychiatric
consultation. They noted that children who were referred or considered
for referral had scored significantly higher on the three questionnaires
used for initial assessment--the to provide appropriate services to deal
with this state of affairs.

We set out to determine the prevalence of behavioural problems
among children living in Uyo, a town in South-South Nigeria.

Materials and methods

Uyo is the capital of Akwa Ibom State, one of six states in
South-South Nigeria. We studied 572 schoolchildren aged 6-12 years from
six schools over a 4-month period (April-July 2006).

Ethical approval was obtained from the Ethics Committee of the
University of Uyo Teaching Hospital before embarking on the study.
Written consent was obtained from the educational board of the state,
and verbal consent was obtained from all the head teachers of the
selected schools. Informed verbal/written consent was also obtained from
the parents of the study subjects.

Primary schools in Uyo were grouped into private and government
schools. Three schools were selected from each group by random sampling
using the ballot method. For each grade, the ballot method was used to
select a class. Six classes were selected from each school. All the
pupils from the selected classes were interviewed to identify those with
chronic diseases such as sickle cell anaemia, epilepsy, diabetes
mellitus and bronchial asthma. Information in this regard was also
obtained from the parents. Because these diseases are significantly
associated with behavioural disorders, pupils with any history
suggestive of such ailments were excluded from the study.

The IQ of each subject was assessed using the Draw-A-Person Test
validated for Nigerian children. (18) Pupils with a score of [greater
than or equal to] 75%, considered a normal score, were included in the
study. Eighteen pupils who satisfied the inclusion criteria were
selected from each of the classes by a systematic sampling method and
constituted the study subjects.

The Rutter behaviour questionnaires, which have been found to be a
reliable and valid instrument in a range of socio-cultural settings,
were used for this study. The Rutter behaviour questionnaire (B2) for
teachers consists of 26 items of behaviour commonly displayed by
children, to which the respondent is asked to indicate whether the
statement 'certainly applies', 'applies somewhat' or
'does not apply' to the child in question, with respective
scores of 2, 1 or 0. The total score for an individual child therefore
ranges from 0 to 52. A score of 10 and above indicates that a child has
behavioural problems. The questionnaires were completed by the
children's teachers, who had been trained in use of the
questionnaire by one of the authors. To ensure that the teachers had had
sufficient contact with the pupils, the study was done in the third term
of the academic year. The author was present to answer any questions
while the teachers filled in the questionnaires.

Parents of the selected pupils filled out the Rutter behavioural
questionnaire for parents (A2). The scale consists of 31 items
concerning the child's behaviour, and the parents indicate the
extent to which each item applies to the child. Each item is scored 0, 1
or 2, as for the teacher questionnaire, so the total score ranges from 0
to 62. A child is considered to have behavioural problems if he/she
scores 13 or above. Parents were visited at their homes in the evenings
to fill in the questionnaire. The few parents who were not at home were
invited to the school to fill it in. The author was available to answer
questions, and to translate the items in the questionnaire into the
native language for parents who could not speak English. Parents were
also asked to state their occupation and educational attainment. Social
classification was done using the scheme proposed by Oyedeji, (19) which
is used extensively in the Nigerian environment. Subjects are classified
into five grades (I-V) based on their occupational and educational
levels. Grade I, which represents the highest social class, comprises
senior public servants, professionals, large-scale businessmen and
contractors, with university education or its equivalent. Grade II
comprises intermediate civil servants and senior school teachers with
secondary education and some further training, grade III junior school
teachers, drivers and artisans with secondary education, grade IV petty
traders, labourers and messengers or other related workers with primary
education, and grade V (the lowest social class) the unemployed,
students, full-time housewives and subsistence farmers with no formal
education. This system was used to assign a social class to each of the
subjects, and the grades were then regrouped into upper (I and II),
middle (III) and lower (IV and V).

Statistical analysis was done using SPSS version 13. Student's
t-test was used to compare pairs of means and the chi-square test for
associations. Yates's corrected chi-square test or Fisher's
test was used as appropriate. The level of significance was taken as
p<0.05.

Results

During the 4-month study period, a total of 648 pupils who met the
inclusion criteria were recruited. However, 76 were dropped as a result
of unavailability of their parents or a substitute after several visits
to their homes to fill in the questionnaires, leaving 572 subjects for
the study.

Table I shows some demographic characteristics of the subjects
according to type of school. The majority (62.8%) of the pupils were in
the age range 6-9 years, with 37.2% in the range 10-12 years. The median
age of the study population was 9 years. There were 284 males and 288
females, with a male/female ratio of 0.99:1. There was no striking
difference in the proportion of males and females recruited into the
study, but more females attended private schools than public schools
(p=0.04). More of the children from the higher socio-economic class
attended private schools, while more from the lower socio-economic class
attended public schools (p=0.001).

A total of 132 pupils (23.1%) had Rutter scores of 10 and above on
the teachers' scale, while 103 (18.0%) had scores of 13 and above
on the parents' scale. The difference was statistically significant
([chi square] = 19.8, p=0.001).

Type of school significantly affected the prevalence of behavioural
problems among pupils according to the teachers' scale, which
indicated that 52 (16.7%) and 80 (30.8%) children attending private and
public schools, respectively, had behavioural problems ([chi square] =
5.89, p=0.001). The mean scores for all the children in private and
public schools were 5.12 (standard deviation (SD) 6.25) and 7.4 (SD
6.41), respectively. This was statistically significant (t=4.04,
p=0.001).

The parents' scale indicated that 50 and 53 children attending
the private and public schools, respectively, had behavioural problems.
The difference was not statistically significant ([chi square] = 1.83,
p=0.18). Mean scores on that scale for all the children were 6.9 (SD
5.76) and 7.39 (SD 5.94) for the private and public schools,
respectively (t=0.68, p=0.5).

Table II shows the age and gender distribution of children with
behavioural problems according to the teachers' and parents'
scales. The proportion of children with behavioural problems increased
with age, but there was no significant difference in prevalence
according to age (p>0.05).

Significantly more males than females had behavioural problems
according to both scales (p=0.004 and p=0.001 for teachers' and
parents' scales, respectively).

Table III shows that according to the teachers' scale the
proportion of children with behavioural problems was highest (31.4%) in
the lower social class. The differences in the proportions of children
with abnormal behaviour between the social classes were significant. The
parents' scale showed no significant differences in this respect.

Out of the 132 pupils with behavioural problems according to the
teachers' scale, 90 (68.2%) had antisocial features, 33 (25.0%)
neurotic features and 9 (6.8%) undifferentiated behavioural problems,
respectively (Table IV). Of all the children with antisocial behaviour,
68.9% were males, and of the children with neurotic features, 60.6% were
females. Both scales indicated a significant difference in this type of
problem between the genders ([chi square] = 16.74, p=0.001 and [chi
square] = 14.41, p=0.002 for teachers' and parents' scales,
respectively). Type of school attended and age did not significantly
influence the type of behavioural problems noted (p=0.05).

Discussion

This is one of the few childhood behavioural studies in Nigeria in
which both teachers' and parents' scales have been used. The
majority of the pupils were in the age group 6-9 years, despite the fact
that equal numbers of pupils were recruited from each class. This is not
surprising, since age at school entry has dropped drastically, to the
extent that some pupils complete their primary education by the age of
10 years.

The equal sex distribution noted in this study is encouraging. In
an analysis of data on the Nigerian education sector, Moja (20)
documented gender disparity in the pattern of school enrollment,
reporting low female enrollment in the northern region and low male
enrollment in the south-eastern region. Some boys in the southern part
are recruited as apprentices in workshops or marketplaces, while the
girls in the north are denied education ostensibly on religious grounds.

There was a higher concentration of children from the upper social
class in private schools, probably because the standard of education in
the public schools is perceived as having deteriorated so much that
those who can afford it send their children to private schools where
teaching is considered to be better.

The overall prevalence of behavioural disorders according to the
parents' scale was 18.8%. This is similar to earlier reports by
Adelekan et al. (14) in Ilorin and higher than 11.8% reported by Eapen
et al. (2) in the United Arab Emirates. The prevalence of behavioural
problems according to the teachers' scale was 23.1%. This is higher
than figures for schoolchildren in Saudi Arabia (5) (13.4%), the United
Arab Emirates (21) (16.5%) and other developed and developing countries.
(2,5,6,22) Iloeje (23) from Enugu in south-eastern Nigeria found a
prevalence of 22.6% in his study of children with sickle cell anaemia.
There is considerable evidence that children with chronic illnesses have
increased levels of emotional and psychological disturbances, which may
amount to a psychiatric disorder. (19,22) Our finding of a high
prevalence of behavioural problems despite exclusion of children with
sickle cell anaemia and other chronic illnesses is noteworthy.
Environmental and socio-demographic factors may be responsible for this
high figure.

The differences between the prevalences of behavioural problems
reported by the teachers and the parents may be due to the protective
attitude of parents towards their children, to the extent that a parent
may not want to divulge his child's worrying behaviour to an
outsider. Previous studies have also shown that parents and teachers
report behavioural problems to different extents in the same children.
(1,16)

Our finding that behavioural problems were more common in males
(60.6%) is consistent with earlier reports on gender difference in
childhood behavioural disorder. (2,3,6,14) Antisocial features were
found to be more common in males, while neurotic problems were more
common in females. These findings are in accordance with previous
reports. (2,4,5) We also found that behavioural problems were more
common in the older children. Behavioural problems have been reported to
increase with age in some settings. (21)

The effect of socio-economic status was significant according to
the teachers' scale (p=0.001), children from the lower
socioeconomic class having a higher prevalence of behavioural problems
than those from the higher socio-economic class. The same tool has shown
low socio-economic status to increase the risk of psychiatric disorders,
(19,21) and it is commonly reported to be a risk factor for psychiatric
problems. (24-26)

It is interesting to note that the parents' scale revealed no
association between behavioural disturbance and socioeconomic status. In
our culture parents tend to protect their children, attempting to
conceal some behavioural traits to avoid stigmatisation. Using the same
tool, Eapen et al. noted no association with socio-economic status. (2)

Behavioural problems were more common in pupils from government
primary schools than in those from private primary schools. This
probably reflects the strong association between private schools and
higher socio-economic class on the one hand and between government
schools and lower socio-economic class on the other. If behavioural
problems are more likely in the lower socio-economic classes, they are
more likely in the government schools.

Conclusion

Our findings suggest that a significant number of children from Uyo
have behavioural problems, with the prevalence of antisocial behaviour
being high in both male and female schoolchildren. It also supports the
possibility that parents report behavioural problems to a lesser extent
than teachers. This state of affairs calls for government to provide
comprehensive child mental health programmes. Among other advantages,
these may reduce the rate of antisocial activity in Nigeria.

(11.) Rishel C, Greeno C, Marcus S, Shear M, Anderson C. Use of the
child behaviour checklist as a diagnostic screening tool in community
mental health. Research on Social Work Practice 2005; 15: 195-203.